Emergency medicine

Re: “Parallel infusion of hydrocortisone ± chlorpheniramine bolus injection to prevent acute adverse reactions to antivenom for snakebites”, by Gawarammana I B, et al in the 5 January issue of the Journal (Med J Aust 2004; 180: 20-23). As a result of a programming error, the confidence intervals in Box 3 of the article were incorrect. Box 3 should be as follows. 3: Reactions to antivenom and time from antivenom infusion to reaction Reaction Treatment A (n = 10) Treatment B (n = 21) Treatment C (n = 16) Mean time (min) Patients Mean time (min) Patients Mean time (min) Patients No. % (95% CI) No. % (95% CI) No. % (95% CI) Hypotension (< 120/80 mmHg) 43 5 33% (15%–58%) 26 8 38% (21%–59%) 22 9 56% (33%–77%) Tachycardia (> 80/min) 42 5 33% (15%–58%) 18 7 33% (17%–55%) 16 10 63% (39%–82%) Rigors 90 1 7% (1%–30%) 38 6 29% (14%–50%) 16 3 19% (7%–43%) Itching 25 10 67% (42%–85%) 16 10 48% (28%–68%) 13 10 63% (39%–82%) Urticaria 32 10 67% (42%–85%) 19 8 38% (21%–59%) 15 12 75% (51%–90%) Dyspnoea 15 2 13% (4%–38%) — 0 — — 16 5 31% (14%–56%) Treatments: A, hydrocortisone and placebo; B, hydrocortisone and chlorpheniramine; C, placebo and placebo. The html and pdf versions of the article appearing in the eMJA were corrected on 19 April 2004.

S Abeysingha M Kularatne MB BS, MD, MRCP(UK) · Indika B Gawarammana MB BS, MD

Kidsnet was established in 1997 at the Children’s Hospital at Westmead as a paediatric telephone triage service. The demand for Kidsnet increased from 18 327 in 1997/98 to 22 844 in 2001/02, with an average of 1669 callers per month. Most callers were able to proceed to seeking care at a more appropriate time and were satisfied with the service provided. The service is highly valued and the advice given perceived to be accurate. Kidsnet has shown that it can play a key role in providing safe advice to families.

Ralph M Hanson FRACP, FACEM, MPH · Bronwyn J Exley RN, GradDip(Paed) · Paul Ngo BSc · Maureen P Fitzpatrick BPhty(Hons), MCogSc · Elizabeth L Petering RN, BN, GradDip(Paed) · Sara J Matthews CNS · Diana Lechner RN · Celeste J Daniels RN, GradDip

James Tibballs,* Sharon Kinney† * Associate Director, Intensive Care Unit, Royal Children’s Hospital, Flemington Road, Parkville, Melbourne, VIC 3052; † Lecturer, School of Nursing, University of Melbourne, Melbourne, VIC. james.tibballsATrch.org.au To the Editor: The introduction of a medical emergency team (MET) at the Austin Hospital significantly reduced cardiac arrest and deaths, and reduced time spent by survivors of cardiac arrest in the intensive care unit (ICU) and in hospital.1 We note that the evaluation of the MET was preceded by a 12-month period of education and a 2-month “run-in” period before the effects of the MET were analysed. We would be interested to know the incidence of death and cardiac arrest, and the duration of ICU and hospital admission in survivors of cardiac arrest during these two periods. Another MET service also claimed substantial benefits in patient outcomes,2 but was criticised on the basis that the results may have been due to better education of ward staff in recognising the antecedent signs of cardiac arrest and/or the creation of more “do-not-resuscitate” orders.3 While the latter criticism cannot be levelled at the study by Bellomo et al, no attempt is made to separate out the effects of the lengthy education period and the operation of the MET. This is a pity, because it would have been a relatively simple matter to do so without detracting from the obvious benefit of the service. Why was a 2-month “run-in” period between education and operation of the MET allowed before analysis of results? Was this a post-hoc decision or were there foreseeable difficulties during the introduction of the MET? Did patient outcomes change during these two periods compared with the period before the MET?

James Tibballs · Sharon Kinney

Rinaldo Bellomo Director, Department of Intensive Care, Austin and Repatriation Hospital, Studley Road, Heidelberg, VIC 3084. Rinaldo. BELLOMOATarmc.org.au In reply: Tibballs and Kinney raise important questions about our trial of a medical emergency team (MET).1 My colleagues and I are, in fact, currently studying these issues. Preliminary (not fully double-checked) data show that during the education period there were 69 cardiac arrests — an average of 23 cardiac arrests per 4-month block. This is a clear reduction from the 63 recorded during the 4-month control period and similar to the 22 cardiac arrests reported during the 4-month MET period. These 69 cardiac arrests led to a total of 227 intensive care unit bed-days or a 75 bed-day average for each 4-month block, about 50% of the number recorded during the control period, but more than twice as many as during the MET period. These patients remained in hospital for a total of 986 hospital bed-days or 328 days per 4-month block, close to an 80% reduction compared with our control period, and twice as many as the number achieved during the MET period. Unfortunately, although we are pursuing mortality data, we won’t be able to provide them for another 6 months because of a changeover in the computer system at our hospital. Tibballs and Kinney are invited to contact me directly by mid-2004. The 2-month run-in period was chosen prospectively, as we expected that the uptake of the MET (a major change of culture) might be slow and require time and encouragement. We were wrong: the MET was taken up with zest and enthusiasm. The histogram (Box 4) in our article1 shows no cardiac arrests during the run-in period, not because they were not recorded, but because there were literally none for 2 months in a row! Obviously, there were also no post-cardiac-arrest bed-days. Again, mortality figures for this period should be available by mid-2004. As we stated in the Discussion of our article, the educational program associated with the MET may indeed have been partly responsible for the findings. We were careful at all times to say that introducing the MET was effective, not the MET per se (see Conclusion).1 We are not aware of any prospective studies testing the effectiveness of introducing a hospital-wide education program aimed at increasing awareness of the significance of physiological instability. Our findings support a powerfully beneficial role of education, but only represent a post-hoc analysis and require validation in other settings and institutions. The role of education was prospectively and separately investigated in the recently completed multicentre cluster-randomisation MERIT study (Medical Early Response Intervention and Therapy). Its results should be available in the second half of this year.

Rinaldo Bellomo

Objective: To determine the clinical significance of definite bites by mouse spiders (Actinopodidae: Missulena spp.) from published case reports/series and museum records.Data sources: A computerised literature search of MEDLINE and EMBASE was undertaken. All cases reported to major Australian museums and reports from venom researchers working with mouse spiders were also reviewed. Textbooks on clinical toxinology were searched and further reports of cases were located.Study selection: All cases of definite spider bites where the spider was collected and identified by an expert as a mouse spider were included.Data extraction: All reports were evaluated and the following data extracted: patient demographics (age, sex, geographical location, season), bite site, local and systemic effects, and hospital attendance. Clinical effects were classified into three groups: severe neurotoxic envenoming, local neurotoxic effects or mild systemic effects, and minor local effects.Data synthesis: Forty definite bites were identified from around Australia, with only one case of severe envenoming (a 19-month-old child). Local neurotoxic effects occurred in six cases and minor systemic effects in five. There was no evidence of envenoming in most bite victims, and the rate of severe envenoming was 2.5% (95% CI, 0–13%). There were no recorded deaths.Conclusions: In most cases, bites by mouse spiders cause only minor or moderate effects. Severe envenoming is rare and far less common than for funnel-web spider bites. Mouse spider bites do not appear to be a major medical problem.

Geoffrey K Isbister MB BS, BSc, FACEM

Objective: To explore the reasons why individuals recurrently present with asthma to hospital emergency departments.Design: A predominantly qualitative study in which participants were interviewed in-depth about their asthma. Data on medication use, respiratory health and asthma knowledge were also collected, and asthma severity was determined from medical records.Setting: A tertiary teaching hospital and a suburban hospital emergency department (ED) from 1 March to 30 April 2000, and a rural hospital ED from 1 July to 31 August 2000.Participants: The participation rate was 32% of an initial 195 ED attendees (183 of whom were eligible) aged 18–70 years: 32 had presented to an ED for asthma care on more than one occasion over the preceding 12 months (reattendees), and 29 were non-reattendees.Results: Two-thirds (22/32) of reattendees had chronic severe asthma and presentation to ED was deemed appropriate for 18 of these, indicated by recurrent severe asthma attacks despite seeking prior medical intervention. Reasons for re-presentation identified in a third of all reattendees included poor asthma knowledge, and financial and other barriers to medication use.Conclusions: We identified potentially preventable issues in about a third of patients (most of whom had mild to moderate asthma) who recurrently presented to EDs for treatment. The remainder of the participants sought emergency asthma treatment appropriately after failing to respond to medical care, and this was frequently in accordance with their asthma management plans.

Dianne P Goeman MA, GradDipSoc · Francis C K Thien MD, FRACP · Jo A Douglass MD, FRACP · Rosalie A Aroni PhD · Michael J Abramson PhD, FRACP · Susan M Sawyer MD, FRACP · Kay Stewart PhD, BPharm(Hons)

Objectives: To estimate the magnitude of access block and its trend over time in New South Wales hospitals, using different definitions of access block, and to explore its association with clinical and non-clinical factors.Design and setting: An epidemiological study using the Emergency Department Information System datasets (1 January 1999 to 31 December 2001) from a sample of 55 NSW hospitals.Main outcome measures: Prevalence of access block measured by four different definitions; strength of association between access block, type of hospital, year of presentation, mode and time of arrival, triage category (an indicator of urgency), age and sex.Results: Rates of access block (for all four definitions) increased between 1999 and 2001 by 1%–2% per year. There were increases across all regions of NSW, but urban regions in particular. Patients presenting to Principal Referral hospitals and those who arrived at night were more likely to experience access block. After adjusting for triage category and year of presentation, the mode of arrival, time of arrival, type of hospital, age and sex were significantly associated with access block.Conclusions: Access block continues to increase across NSW, whatever the definition used. We recommend that hospitals in NSW and Australia move to the use of one standard definition of access block, as our study suggests there is no significant additional information emerging from the use of multiple definitions.

Roberto Forero MA, MPH, PhD · Lis Young FAFPHM, RCAP · Hai N Phung MD, MPH · Kenneth M Hillman MB BS, FRCAnaes(Eng), FFICANZCA · Mohammed Mohsin MSc(Stats), MSc(Demography) · Adrian E Bauman MPH, PhD, FAFPHM · Sue Ieraci MB BS, FACEM · Sally M McCarthy MB BS, FACEM, MBA · C David Hugelmeyer FAAEM, FACEM

Improving safety is important, but in many regions antivenoms are not available Although snakebite has been a subject of medical interest since antiquity, and despite it continuing to affect millions of people annually,1,2 it remains one of the neglected health problems of the tropics.1-3 Today, almost lost amidst the preoccupation with shortages of vaccines and antiretroviral medication in the developing world, there is a crisis in antivenom availability in the very same nations.3 In response, the World Health Organization recently held its first antivenom workshop in more than 20 years, to discuss the global supply and quality of antivenoms.4 However, perhaps more importantly, a growing community of physicians from the regions with the greatest snakebite burden have become more active in seeking solutions to at least some part of this ancient problem. The study by Gawarammana and colleagues in Sri Lanka (page 20) is one example of such scholarship.5 It is a welcome addition to the relatively scant clinical trial literature examining the management of snakebite. In a well conducted but underpowered study, the authors document a reduction in mild-to-moderate acute reactions to antivenom with an antihistamine bolus in conjunction with a hydrocortisone infusion. However, in the clinically important endpoints of moderate and severe reactions, there was insufficient power to confirm a trend toward fewer reactions in the hydrocortisone-containing regimens. This study is in contrast to a previous study from Brazil that failed to demonstrate any difference in early antivenom reactions with prophylactic promethazine alone.6 Most notable in this and an earlier Sri Lankan study,7 which assessed subcutaneous adrenaline as prophylaxis against acute antivenom reactions, was the extremely high rate of such reactions — in this study, almost half the patients had moderate or severe reactions sufficient to require adrenaline. This differs considerably from the rates in Australia (reported as 10% in the absence of premedication8 and 4.6% with premedication9). Snake antivenom is derived from antibodies of immunised animals; the rates of reactions appear to vary with the species of antibody origin, the extent of pepsin digestion, the presence of molecular aggregates and the total protein content of the product.4,10 It has been presumed that most acute reactions relate to the extent of complement activation from Fc receptor binding,10,11 with improvements in quality having largely resulted from enhancements in antivenom processing.4 However, the recent WHO workshop called for a re-examination of old assumptions concerning such reactions and, consequently, what constitutes “best practice” for antivenom manufacture and administration.4 Although Sutherland attributed the low reaction rate to Australian snake antivenoms to a series of refinements in the recommendations from the former Commonwealth Serum Laboratories concerning antivenom administration, including the practice of prophylactic use of adrenaline and hydrocortisone,9 current national reaction rates and associated clinical practice remain unclear.12 It is intended that recently introduced refinements to the Australian coding standards for ICD-10-AM (third edition)13 will assist in closing this gap in the national toxinology evidence base. However, because of the inherent delays in the collation of national statistics, and as current methods are far from complete,12 it would seem appropriate to mandate reporting of adverse antivenom reactions to facilitate appropriate follow-up. Such a system is in place in Brazil.14 Meanwhile, there is a dichotomy in current premedication recommendations for reducing acute reactions to snake antivenoms in Australia. In Australia’s toxinology textbook,15 Sutherland and Tibballs considered the evidence available up to 2001 and concluded that “premedication with subcutaneous adrenaline is recommended (0.25 mg for an adult, 0.005 mg/kg for a child) before antivenom therapy”. By contrast, a recent review by Currie concluded: “with the very low rate of severe reactions to antivenom seen in Australia . . . and the ability of emergency medicine physicians to adequately manage reactions that may occur, a policy of withholding premedication but always having adrenaline drawn up and ready is now recommended by many authorities and is policy in the Northern Territory”.16 In the middle is Australia’s antivenom manufacturer, CSL Limited: “Some authorities have advocated premedication with subcutaneous adrenaline and intravenous antihistamine, particularly in those patients who are known to be at risk, but such use is controversial”.17 Readers should consult the references for further details of the respective arguments and the history and evolution of the manufacturer’s recommendations.8,9 Although it is likely that well staffed major hospitals can, if it is recognised early, readily and rapidly manage antivenom reactions, such events can be severe, progressive and are not necessarily remediable.18 Therefore, it is the small rural centres, with more limited staffing and facilities, that may benefit most from the apparent efficacy of adrenaline premedication.7,9,15 If premedication is to be given, currently the best evidence is that it should be subcutaneous adrenaline.7 However, it is notable that Sutherland himself was agreeable to some “alternative but equally effective replacement for adrenaline”.9 And so we return to the search in Sri Lanka for such a replacement (or adjunct). The apparent benefit from the combination of an H1 antagonist and hydrocortisone described here suggests that a combination of H1 and H2 blockers may bring additional benefit, as has been proven for the treatment of acute allergic syndromes.19 However, the applicability of this study, in which a poor-quality antivenom resulted in extreme reaction rates, to the situation in Australia (where low reaction rates are reported) is uncertain. Interestingly, the antivenom used (the Haffine polyvalent snake antivenom) appears to be an equine Fab2 product,20 the same as that used in Australia.17 The Indian antivenom that was used in Sri Lanka, however, is a lyophilised preparation5, whereas the Australian antivenom is a liquid product. Therefore, aside from the premedication issue, there are clearly opportunities to improve the reaction rate by improved processing of this Indian product.4 Unfortunately, these debates are irrelevant for most people affected by snakebite, predominantly in the rural tropics. For example, in Papua New Guinea the high cost of Australian antivenoms puts adequate supplies beyond the reach of the health budget.2 For people in countries where the available antivenoms are of poorer quality, studies such as these, even if they only demonstrate reductions in reaction rates from 80% to 50%, are applauded; more are sorely needed. But for most countries where antivenoms are unavailable or unaffordable, there is little to do but measure smoke from the burning house while praying for rain.

Allen C Cheng MB BS, FRACP, GradDipClinEpid · Ken D Winkel BMedSci, PhD, FACTM

Objective: To investigate the efficacy of continuous infusion of hydrocortisone with or without chlorpheniramine bolus against early adverse reactions to polyspecific antivenom.Design and setting: Prospective, double-blind, randomised, placebo-controlled trial at General Hospital, Anuradhapura, Sri Lanka.Subjects: 52 patients with snake envenoming were randomised to receive infusion of hydrocortisone (Group A), hydrocortisone with chlorpheniramine bolus (Group B) or placebo (Group C) during the administration of antivenom.Intervention: Hydrocortisone 1000 mg in 300 mL of normal saline infusion was started 5 min before and continued for 30 min after antivenom. Chlorpheniramine 10 mg intravenous bolus dose was given 5 min after commencement of antivenom.Main outcome measures: Occurrence and severity of adverse reactions to antivenom.Results: Adverse reactions were observed in 80% (12/15) of Group A, 52% (11/21) of Group B, and 81% (13/16) of Group C. Reactions were mild or moderate except in two patients. A significant reduction in the number of adverse reactions was seen in Group B compared with the placebo group (difference, 29 percentage points; 95% CI, 0.2 to 58 percentage points). There was no significant difference between Group A and the placebo group.Conclusion: Prophylaxis with a parallel hydrocortisone infusion alone is ineffective in reducing the occurrence of acute adverse reaction to antivenom serum, but combining it with chlorpheniramine seems efficacious.

Indika Bandara Gawarammana MB BS · S Abeysingha M Kularatne MB BS, MD, FRCP(UK) · Ranjith P V Kumarasiri MB BS, MSc, MD · Nimal Senanayake PhD, DSc, FRCP · Wasantha P Dissanayake MB BS, DCH, MD · H Ariyasena MB BS, MD, MRCP

Objective: To describe an outbreak of Plasmodium vivax malaria in Far North Queensland in 2002.Design: Epidemiological and entomological investigations; molecular analyses of the infecting parasites.Main outcome measures: Case characteristics, adult and larval mosquito counts at the outbreak location, haplotyping of parasites in blood samples from different cases determined through sequencing of AMA1 and MSP1 genes.Results: A man with imported P. vivax malaria stayed at a camping ground 95 km north of Cairns in late September 2002. This led to an outbreak of P. vivax malaria in 10 adults who stayed at the camping ground in October. Large numbers of Anopheles farauti sensu lato larvae were present in stagnant pools in a creek at the camping ground, and many adult mosquitoes were collected nearby. Not only had most of the infected patients been exposed to mosquitoes at night, they were also less likely than other campers to have used insect repellents appropriately (odds ratio, 0.01; P < 0.001). Two different haplotypes of P. vivax, only one of which was detected in the imported case, were involved in the outbreak.Conclusions: Although local transmission of malaria is rare in Far North Queensland, the risk is probably higher in the dry season (September to December). Campers need to be aware of the increased risk of mosquito-borne diseases. Sexual recombination of multiple gametocytes in mosquitoes infected by the imported case may have resulted in the two haplotypes of P. vivax involved in the outbreak.

Jeffrey N Hanna MPH, FAFPHM · Scott A Ritchie PhD · Dianne L Brookes MPHTH · Brian L Montgomery MSc · Damon P Eisen MD, FRACP · Robert D Cooper PhD

Bryan G Walpole Emergency Physician, Australian Antarctic Division, Channel Highway, Kingston, TAS 7050. bwalpoleATtassie.net.au To the Editor: Your otherwise excellent issue on chronic illness (1 September 2003) was timely and appreciated. However, the article by Zajac on the future of public hospitals1 left me pondering how frequently he patrolled the wards and the emergency department. Most public hospitals have undergone the very revolution he adumbrates. Patients now arrive with automated medication records and problem lists from their general practitioner; GP liaison doctors from the Divisions attend discharge planning committees; discharge summaries are delivered by fax on discharge; multidisciplinary clinics abound for complex and chronic illness, but invited GPs claim that time commitments and insufficient payment often preclude attendance; there are target waiting times for clinic appointments; often there is a quality assurance unit, with a complaints or grievance procedure; day surgery and day of admission surgery is now the norm (and strict guidelines help control the morbidity Zajac bemoans), with vastly improved throughput; endoscopy and emergency cardiac catheterisation or angioplasty on demand are commonplace; we now acknowledge, document and rectify system errors with alacrity, without the rancour and recrimination of years ago; and evidence has replaced the wise maxims of the physician. Admittedly, all is not rosy and funding remains a perennial problem, but within available resources the public hospital is a completely different place from 15 years ago. A major issue, and Zajac agrees, is the place of general medicine in the public hospital, being rapidly subsumed by sub(super)-specialists together with emergency physicians, as they are available round the clock, skilled and equipped to perform the assessment and early management of most medical patients, while the physicians are in rooms or at home. We welcome the presence of general physicians in the emergency department, and encourage twice-daily rounds on admitting day with shared care, but so far the rhetoric of general medicine has rarely been matched by attendance. The real challenge for public hospitals at present is to effectively manage and discharge frail elderly patients, and those with cognitive impairment, thus keeping beds free to reduce access block; otherwise general medicine may suffer the fate Zajac reserves for public hospitals and become “a thing of the past”.

Bryan G Walpole

Jeffrey D Zajac Head, Department of Medicine, Austin Hospital, Level 7, Lance Townsend Building, Studley Road, Heidelberg, VIC 3084. j.zajacATunimelb.edu.au In reply: Walpole and I agree that public hospitals have changed significantly. Where we seem to disagree is that he suggests that we have got to where we are going and all the problems have been solved. Walpole clearly works in a different world from me. Even a short visit to the wards and emergency department reveals that, despite good will, planning and many of the changes Walpole lists, things are far from perfect. System errors, major and minor, occur far more commonly than they should, elderly patients spend more time as inpatients than they should, and stresses in the system continue to impair quality and efficiency. I think we need to keep working on these issues, and not pretend that they are fixed. I note with dismay the description of general physicians occasionally visiting Walpole’s emergency department, while other specialists work diligently, 24 hours a day, to heal the sick. These comments demonstrate one of the main problems with doctors in public hospitals, namely, the territorial imperative in full flight. We should be finding ways to work together.

Jeffrey D Zajac

Using Botulinum toxins cosmetically. Jean Carruthers, Alastair Carruthers. London: Martin Dunitz, 2003 (v + 81 pp + CD-ROM). ISBN 1 84184 217 6. Botulinum toxin is mainly known in Australia as Botox, one of its popular trade names. It has become a household word, not so much for its use as an exciting drug in almost every field of medicine, but as a deadly poison that has been somehow transformed into a softener of facial expression lines. This book on its cosmetic uses is a timely work indeed. Jean and Alastair Carruthers are the mother and father of the aesthetic use of botulinum toxin. Jean, an ophthalmologist, and Alastair, a dermatologist, first noted the softening of expression lines in some patients being treated for oculospasm in the 1980s. From then on, through their relentless application of science and artistry, they have steered the course for the safe treatment of expression lines, initially of the upper face, and more recently those of the mid and lower face and neck. Botulinum toxin injected in doses used for cosmetic enhancement appears to be a very safe treatment without much risk to the patient’s general health. However, there may be local effects, and the emphasis of this book is very much "safety first" through optimal dosing and careful injection placement. This short text presents the most up-to-date factual information that I have seen, and the accompanying procedural CD-ROM is a most interesting and highly effective teaching aid. Even the most experienced injector will learn tips and tricks from this work. This book simply and succinctly acts as a step-by-step guide to the injector, but I feel it is being directed to those with some experience, rather than the complete novice — it should not substitute for mentoring and formal training. I would have liked to see the patients in the CD-ROM after their treatment, so the attempted outcomes and their subtleties could have been shown, but otherwise it is a wonderful instructional aid. Gregory J GoodmanDermatologistSkin and Cancer Foundation, Toorak, VIC

Gregory J Goodman

All crew on deck. But keep the emotions stowed away Every doctor knows the feel of a medical emergency. You’re sitting at the nursing station when the patient in Bed 4 has an arrest. You’re in the middle of performing a routine procedure on a patient when the patient’s blood pressure plummets. You’re sitting in the emergency department when an ambulance paramedic commands your attention — “Two multitraumas, doc. They’re pretty bad.” Any normal person would be anxious or afraid or despairing, but you can’t afford to be. Your attention is focused on the problem at hand. You run through the possibilities and formulate a plan of attack. The fact that the person in front of you is likely to die in front of you is only another element in the equation. You can’t let emotions get in the way, or you’ll be less efficient and less likely to succeed. You are working in a surreal, glassy atmosphere, temporarily detached from your emotional life. That’s what is required in an emergency. For most of us, though, emergencies are rare events, or at least have been since we left our intern and resident days behind. But, for the staff of emergency departments, emergencies are an everyday affair. What effect does this have on the staff? Does the frequent need to switch off their emotions change them in some way? Does it alter their relationships with patients? Does it affect their private lives and families? No one doubts that exposure to traumatic events can have a profound impact on an individual. Post-traumatic stress disorder (PTSD) is well characterised and understood. People who experience PTSD often say that their most disabling symptom is a kind of “psychic anaesthesia”, which may manifest as a constricted emotional responsiveness. They complain that they have lost the ability to fully engage with other people or fully enjoy normal activities. Emergency department staff are not generally thought to suffer PTSD, but it may be pertinent to ask whether they experience some of the typical features of the disorder. Do they suffer a heightened general anxiety? Do they experience flashbacks of their work experiences? If so, we know very little about it, as there is almost no published material on the subject. In this issue of the Journal, four very different articles explore death in the emergency department from an individual perspective. Edwards (page 647) shares with us a very personal perspective on his experiences as an emergency physician. Using a uniquely Australian analogy, Edwards says he copes with deaths in the emergency department by donning a “Ned Kelly suit of armour”. As he looks back over his responses to a series of deaths, he wonders if his armour has remained a useful tool or become a prison. The metaphor of the man of iron is particularly apt given that the original suit was eventually to prove fatally flawed. Articles by O’Reilly et al (page 649) and Fulde (page 651) examine the care of homeless people in the emergency department. They present case histories of homeless patients who had become well known to emergency department staff and eventually died. Both pieces examine the question of what sort of relationship emergency staff can have with this kind of patient. Both play on the tension between the fantasy that the emergency staff were the homeless men’s “family” and the reality that the men had no family at all. Humour is a tried and true defence against emotional trauma, and Fatovich’s satirical study into the mortality of anonymity is as dark as it is funny (page 653). For all of these contributors, the feeling of having to switch off emotionally when dealing with a crisis is probably all too familiar. Every doctor has experienced the same feeling from time to time, but what can it do to you if you feel like that all the time?

Christopher J Ryan MB BS, FRANZCP · Robert P Dowsett BM BS, FACEM

Don your armour, but beware of the chinks I was recently showing my two young children around the grounds of my former high school, when I was reminded of our old school sergeant — the onsite caretaker of the school. He was a large man who would often drop unannounced into a classroom, stay for a couple of minutes taking in part of our lesson, and then leave. As pupils we had to stand on his entry and stand on his leaving — a somewhat distracting ritual for the pupils and teacher. The school sergeant would grab just a snapshot of our lives and learning, and leave. As I reflected on this, I began to think that his somewhat disconnected life with the pupils had similarities with emergency physicians’ relationship with death in the emergency department. Death is unfortunately part of the job of an emergency physician. The death I deal with is usually stark, sudden and shocking. It is often ugly — we are confronted with battered and bruised bodies, which we then further assault with pieces of plastic that protrude from various parts of the person. Having to tell relatives that their loved one is dead is never an easy task. Often what makes it even harder is that these relatives were talking to the patient just a few hours before, when the person appeared completely well, or, even worse, were present when the life-shattering event happened. A recent example was the case of a young woman who had been walking down the road hand in hand with her boyfriend when he was hit by a car. We were unable to resuscitate him in the emergency department. Having to break this news to the girlfriend, who was brought in uninjured a little later by ambulance, was not a task I relished. I spent as much time as I could with her, which on that typically busy evening probably amounted to no more than 10 minutes, and then left her with our social worker. I had a number of other sick patients to review, bed managers pressuring me to clear the department to make beds available for other patients lying on ambulance trolleys, as well as all the paperwork to do for the unfortunate young man who had just died. I was reminded of my school sergeant: I had popped into this young woman’s life — at a time of the most acute anguish and stress — and then rapidly moved on. I did in fact have to walk past her a few more times during the course of the shift while she was sitting with the social worker, but I made no more real contact with her. Despite feeling for her I had to move on — there were more patients to see. Back in 1997, I was part of a medical disaster team deployed to the scene of the Thredbo landslide. Our team was the last to be deployed, and our role was to deal with the medical needs of the over 1000 rescue workers and also to certify the remaining victims once they had been extracted from the crushed lodges. I was taken on a tour of the site — a tangled, flattened mess of concrete and metal — and was struck by the number of simple personal items of the victims that were still strewn around: books, photographs, toothbrushes and the like. This really brought home to me that the victims had had their lives so violently and unfairly taken from them and their loved ones. However, when I had to certify the last four victims — all cold, stiff and crushed — I performed this with perfunctory precision. In order to deal with these aspects of my work, I have developed something like a Ned Kelly suit of armour — an outer hard shell that protects me from the bullets of misery, anguish and stress of people sick and dying; a mask that prevents too much eye contact, and therefore emotional connection, while at the same time preventing the emotion within me from escaping and being seen in the raw. This piece of armour protects me by putting some emotional distance between me and the patients I am dealing with, and allows me to face the onslaught that working in an emergency department often is. But this Kelly suit concerns me. Does it mean, by definition, that the system and specialty in which I work requires that I don the suit to work effectively, or have I put it on myself because I have become somewhat hardened to the human tragedy I deal with? And, more importantly, whatever the answer to this “chicken or egg” type of question, how is this affecting me elsewhere in my interactions with patients as well as my day-to-day interactions with family and friends? I think a major reason most people go into medicine is because they like people and want to help them, and for me that drive is still there. However, the increasing workload and demands of the emergency department mean that I often feel unable to spend the appropriate amount of time with patients. At times I have to “cut to the chase” with them, and may therefore appear a little brusque or callous. That is certainly not my nature and was not how I started out as an idealistic intern. Does this mean I bring this armour and attitude home with me? Having two children under five certainly requires a lot of time, patience and understanding. I hope that I take the armour off when I am with them, but I can never be 100% sure. Having children has been both a help and a hindrance for my work. I certainly have a lot more understanding of the problems of parents, and I interact more naturally with my paediatric patients than I did before having children. But dealing with the death of a child is a lot harder now. I recall a 6-month-old boy in cardiorespiratory arrest who was brought in a couple of years ago. We worked on him for some time, but our efforts were ultimately unsuccessful. During the resuscitation I could not help noticing that this boy’s fair hair and looks reminded me of my son, who was around the same age at the time. I had to really fight back the tears as I ran the resuscitation, which I knew was going badly. In the past I did not have such an emotional reaction when resuscitating children. So perhaps that shows that the Kelly armour does have some chinks in it. Death in the emergency department constantly reminds me about the fragility of life, and the need to try to live life to the full and to spend as much time as possible with those who are close to you. The other day, a normally healthy 40-year-old woman was brought in after, as the jargon would say, “a witnessed cardiac arrest at home with bystander CPR”. We were unable to resuscitate her. The bystander attempting resuscitation was her 12-year-old son. Many of the patients I see now are in their 70s — the same age as my parents. Fortunately, my parents are both still active and healthy, but when that 70-year-old arrest is called through by the ambulance service on our “bat phone”, I can’t help but think sometimes that one day the patient could be one of my parents. I recently watched the broadcast of the singer Slim Dusty’s funeral, and although I didn’t know the man, I know his son, who is an emergency physician. The service was a very powerful one — one that had tears washing down my cheeks. They were tears of sadness for my colleague and his family, but also, in a tiny way, tears of joy for me, because it showed me that the Kelly armour was removable. They were tears of true and raw emotion. I was reminded again of school and some lines of a Les Murray poem I had studied: The man we surround, the man no one approaches simply weeps, and does not cover it, weeps not like a child, not like the wind, like a man and does not declaim it, nor beat his breast, nor even sob very loudly — yet the dignity of his weeping holds us back from his space, the hollow he makes about him in the midday light, in his pentagram of sorrow, and uniforms back in the crowd who tried to seize him stare out at him, and feel, with amazement, their minds longing for tears as children for a rainbow. (Les A Murray, An Absolutely Ordinary Rainbow.1 Reproduced with permission from the author.)

Keith D Edwards MB BS, FACEM

The human aspect of medical care that statistics ignore Historically, hospitals have acted as a refuge for the sick, the frail, the elderly and the infirm. In some instances, hospitals have been the last option for the less fortunate members of our society seeking help. Hospital emergency departments (EDs) are now one of the few agencies available 24 hours a day to assist people in crisis. But the ED is often stretched to the limit providing its services to all and sundry — encapsulated in the story of a composite patient, “Harry the Hobo”. It is a difficult working environment, in which the prevailing orthodoxy of economic rationalism focuses attention on funding measurable outputs. But our experience suggests that some “outputs” are difficult to measure and, indeed, shouldn’t be measured. At last year’s ED Christmas party, someone noticed that Harry hadn’t yet appeared in the ED. Harry always dropped in during Christmas week. In fact, it was in late November of that year that he had last visited. Some Good Samaritan passer-by had alerted the ambulance to a seemingly unconscious old man lying against the wall in an alleyway. When brought into the ED, he was immediately recognised by the triage nurse. “Harry, what have you been up to this time?” She knuckled him in the sternal area, to check his level of consciousness, and Harry roused with a “F... off!” before slipping back into oblivion. He reeked of stale beer, and pieces of his last meal were spattered down his front, making the hospital gown he was wearing almost unrecognisable. But his tweed cap remained glued to his head, and his brown jacket and socks were on, the latter recognised more by odour than colour. “Put him on that trolley in the corridor there”, the nurse directed the ambulance staff. No observations were done. Why would you? This was Harry. The ED on that night in November was bursting. There were no beds in the hospital, but no one bothered any more to ask why. The only reason the department was not on ambulance bypass was that every other hospital was on bypass already. To move to bypass would create “gridlock”, a consequence that could not be contemplated. So Harry wasn’t very welcome that night. Mind you, he had been only begrudgingly welcome for some years. He was a source of frustration nowadays. Years ago, when his name came up on the screen, the cry of “there’s a good patient for the Intern” would come up. On this occasion, the Emergency Consultant was beckoned by the Nurse in Charge to come and “get rid of him”. Harry’s history notes arrived, or at least the last two volumes of them. Harry’s presentations actually seem to have shortened as the years have passed. His diagnoses have included chronic “burnt-out” schizophrenia, head injury from falls and assaults, atypical chest pain that had been investigated relentlessly, atrial fibrillation for which he was once taking warfarin, haematemesis, melaena and alcoholic liver disease. But few of these have been active components of his presentations in this, his eighth decade of life. Mostly he wakes from his ethanol-induced stupor, and shouts a few expletives relating to his desire for the bottle (urine) and for sandwiches and a cup of tea. On this occasion, he was rehydrated with normal saline. As he had no fixed abode, and given that it was 11 pm, Harry slept on his trolley overnight and left in the morning. His cap stayed on throughout. Over the years, Harry has spoken to many psychiatric triage nurses and many social workers. He used to stay in a men’s boarding house, but was evicted on multiple occasions. Now he sleeps “rough” and his patient registration details record him as being of “no fixed abode”. With no living or caring relative, no general practitioner that he bothers to visit, and no regular publican to have a yarn to, he has nominated the hospital as his next of kin. His most frequent ED diagnosis these days is loneliness. Harry may be lonely, but he is not alone in this regard. For people at the margins of society, the local ED can be a place of solace. Maybe this is more pronounced since the reduction of institutionalised accommodation for people with chronic psychiatric conditions, maybe not. Either way, no manner of community follow-up and support networks can fill the void of loneliness. So into the ED comes a group of people seeking aspects of attention that are often disregarded when assessing clinical workload. They may be young or old, male or female. One study of “unnecessary” ED attendances at a tertiary hospital in Melbourne found that 41% of repeat attenders were homeless.1 They may present with atypical chest pain, a conscious collapse in front of the triage nurse, a request for a repeat script for “sleeping tablets”, or a rash of 6 months’ duration. In the waiting room they may chat to fellow patients or catch up on the football displayed on the television. Often they “entertain” the security guards. Once they “break through the department gates” they may get a trolley, where they can choose to sleep or sit up and observe all the activity around them. The place is warm and active. The frowns or firm words of the staff don’t seem to bother them. Being woken up does though, and their colourful vernacular adds to the liveliness of the work environment. A warm cup of tea, some carrot-filled sandwiches, even a shower and some clean striped clothes from the cupboard — these are some of the “perks” of a visit to the ED. This type of patient challenges doctors and nurses alike. They are an ever-present nuisance, a source of frustration. Trolley space, nursing and medical assessments, food and toileting — these resources are already heavily stretched but nevertheless expected to repeatedly cater to the needs of Harry the Hobo and those of his ilk. Medical care is now heavily regulated and constantly measured. In the ED we must measure waiting times, length of stay, complaints and adverse events, which are then benchmarked against key performance indicators. Workload indices, such as attendances adjusted for casemix, need to be calculated. Patient satisfaction surveys are scored and the results compared with those of other health services. Registries keep a record of outcomes for trauma and other diseases, and various surveillance agencies monitor the incidence of injury and infectious disease. Staff morale is measured by staff turnover, staff satisfaction surveys, and days lost due to sick leave. On the basis of these numbers, management is rewarded or punished and hospitals survive or perish.2-5 With all these measurements and management reviews being conducted, surely a proportionate degree of funding and resources is being allocated to providing “tender loving care” to Harry the Hobo and others like him. Well, no, it isn’t. How do we begin to incorporate such care packages into our workload indices? Should we begin by measuring the vocabulary score? — that is, how many expletives were uttered that we really didn’t wish to hear. Or maybe by Harry’s aroma score and its effects on the environment we work in? Surely showering time, undressing and redressing time are easily measurable. Department “warmth” consumed by the patient might be difficult to measure, as would the pleasure felt by the patient in being recognised by staff. At the very least, though, we should have an index for the number of carrot sandwiches consumed. In mediaeval times, the burden of care for the “not unwell but merely unfortunate” fell on the Church. In 19th century Europe, the mass urbanisation associated with the Industrial Revolution increased the marginalisation of the dispossessed, with the concurrent expansion of multiple secular charities.6 Today, the “Salvos” and the Red Cross Society are just two of the many organisations that serve the so-called “castoffs” of modern-day society. And, despite the economic rationalism of the 1980s and 1990s, health services have attempted to maintain some flexibility in catering for those “consumers” who do not fit neatly into an “illness category”. The ED provides 24-hour access and, thankfully, can refuse admission to nobody. For many people it serves as a refuge, a source of basic comforts and basic human values. It becomes their family. We cannot and should not even attempt to measure the delivery of this service. Indeed, any measure would devalue its true worth to the beneficiaries themselves and to the staff who provide it. One could imagine a situation in which hospitals might adjust the “loneliness score” or manipulate the “compassion index” to maximise income. But the service that is being provided is one of human kindness and compassion — the basis of a civilised society. This human aspect of medical care should be acknowledged and celebrated, rather than measured. Harry the Hobo did eventually visit the ED on Christmas Eve. He had been found cold and unconscious, and on this occasion wasn’t moving his left side. In addition, it appeared that he had subsequently aspirated and now was in respiratory distress. It was clear that this would be Harry’s last visit. He was taken inside immediately, and when the treating nurse saw the tweed cap beside him on the trolley, she realised who this dying man was. The cubicle was quiet and respectful, and the doctor and nurse applied some oxygen, delivered some hydration, and ensured that Harry was comfortable. He died several hours later. Harry was at home with his family for Christmas.

Gerard M O'Reilly MB BS, FACEM · Alfredo Mori MB BS, FACEM, FFAEM · Peter A Cameron MB BS, MD, FACEM

Why do some “frequent flyers” of the ED gain a permanent place in our hearts? Recently, the death of a homeless man who had lived in a bus shelter next to our inner-city emergency department (ED) for a quarter of a century made national and international headlines.1,2 Here, I present the story of this man’s relationship with the ED and also describe our involvement with two other homeless men. Then, I ponder why it is that patients like these can make such an impact on the healthcare workers who come in contact with them. Karl, the bus-stop manAlthough Karl did not present as a patient every day, we saw him in the ED every day, as he used our waiting-room toilet as his own. We found him to be a very quiet, private, polite, kind and gentle man. The nuns and hospital staff (especially the nurses and social workers) would give him tea, biscuits and sandwiches when he visited, but rarely did he accept other offers, such as assistance in securing alternative accommodation. He lived in a corner of a nearby bus shelter, and neither he nor the shelter could be considered pleasing to the discerning nose. We repeatedly tried to coax him into the ED for a clean-up and a new set of clothes. On the odd occasion he did accept the offer of a clean-up — notably on Christmas Eve in 1993, when the hospital notes document that the nurses handwashed his clothes when he wouldn’t part with them. He even allowed us to trim his beard a little, and we did think he looked rather like a Santa Claus. Perhaps it was because of his Christian background that Christmas was the only time he ever seemed to truly relax and enjoy being in the presence of the ED staff. Perusal of Karl’s medical record reveals only seven official attendances, including three overnight admissions under my name. In spite of a past history of alcohol misuse, his health problems had been limited to chronic venous insufficiency, swollen legs, cellulitis and scabies infestation. During one admission, an ED registrar had asked jokingly, “Is it Karl’s birthday?” (in fact, we didn’t know his date of birth, and never did find out). On another occasion, during winter, I had admitted him overnight simply because the outside conditions were harsh and he was fearfully cold. In September 2002, Karl was found dead, of natural causes, in his bus shelter. The outpouring of sympathy for this unassuming man, who had become such a “fixture” in the life of the ED, was amazing. Even in death, his life was an enigma. From what could be pieced together from the locals — people whose children he had helped to catch the bus, shop owners and waitresses from whom he had bought or had received gifts of coffee and food (including bacon sandwiches — his favourite), nuns who crossed the road near his bus shelter on the way to and from their convent (whom he uniquely acknowledged by accepting their gifts and offering a smile and ever-so-rare words), and the nurses whom he had looked out for in the dark as they returned home after working a late shift — it became apparent that he had had a daily routine, a circuit. But he had never let us get to know him and never revealed anything about his history. We felt he was a loner by choice and we respected that choice. Unlike other homeless people we saw in the ED, he was never seen to be intoxicated, rude or aggressive. Karl was a man who spoke with his eyes rather than with words. When he died, many of us truly grieved for this kindly, silent, bearded figure. Harry, the newspaper manAnother younger, homeless man evoked a similar feeling of loss upon his demise — this time, the death actually occurred in our ED. I have written of his case previously,3 partly because of its general medical relevance but also because I found myself, like many others in the ED, emotionally affected by it. Harry was a scrawny, wiry man of 40-something who looked a great deal older than he actually was. We frequently saw him in the streets around the hospital. Any greeting of “Hullo” or “Good morning” that we gave him was returned with gusto. We knew him as the man who sold newspapers. We thought this was his way of earning a little more money, as we knew that he drank. He never talked about himself and never asked for a handout. I remember clearly the morning he was brought into the ED by ambulance, having had a witnessed collapse. Quickly it became evident that he was critically ill — he had septic shock secondary to cavitating pneumonia (Box). However, once we had reversed his profound hypoglycaemia (0.7 mmol/L) and commenced to warm him up from his hypothermia (33.5°C), he just kept apologising to us for being a trouble. Over the subsequent hours, we tried to save his life, and did successfully bring him through a broad complex tachycardia. All the ED staff, including non-healthcare staff, were focused in their concern for him, with everyone requesting frequent updates. Unfortunately, we lost him following an arrest. Although he put up an amazing fight, advanced resuscitation, including defibrillation, could not save him. The ED staff went quiet in their grief. Many, including myself, shed a tear. We knew this patient and he had expressed his appreciation of our efforts — even as he was dying. It turned out that he, like Karl, had been a loner. Before he died, he asked us to contact his only friend — the newsagent who supplied him with papers, basic accommodation and the sincere care that only a friend can provide. There were no relatives and there was no past we could piece together. His absence from the neighbourhood haunted us long after his death. “John”, the “scratchie” man“John”, a street person with drug use issues, is one of our most frequent attendees currently. He is highly intelligent, very manipulative, and almost totally non-compliant with antibiotic therapy for a septic knee and sundry other complaints. Even when coaxed to stay in the ED for treatment once difficult intravenous access has been established, he manages to escape several times a day on crutches or on one of our wheelchairs (generally by using the ruse that he is going out for a “smoke”). On one such outing, he bought a lottery “scratchie”, and on his return asked a nurse to check whether he had won anything. For a while there, we all thought he had scratched himself $50 000; he was festively congratulated and we were all very happy for him. When it turned out that an unfortunate minor technicality meant that he just missed out on his prize, the ED staff immediately passed the hat among themselves so they could buy him another couple of scratchies. DiscussionMany homeless and disadvantaged people use the ED as their main point of access to healthcare and social care.4-6 Outside normal working hours, calling in at an ED may be the only practical option available to them. The three cases described here illustrate the bond that can develop between ED staff and the homeless people who visit at irregular times. ED staff will know which of their regular visitors are living “rough”, either by their address (“no fixed address”, multiple changing addresses, or homeless shelter address cited in the medical record), or by talking to other staff or the patients themselves. Maybe it is because EDs are always available and the staff will, with each presentation, listen to the homeless person’s issues, talk to them and try to work out something for them, that there develops a caring bond between the homeless and ED staff. Why do we care? I have mused often about this question and have asked my staff for their thoughts on the matter. The demanding work of an ED tends to attract staff with certain qualities in common. One is our need for gratification — we want to do things and see results, despite the difficulties. This is not necessarily an easy task — many (but not all) homeless patients are “hard work”. They may present to the ED in a confused or demented state; they may be anxious or plain scared. Some fight to reject any care offered to them; others, because of their personalities, mental-health and/or substance-use disorders,7,8 may be overtly rude, aggressive, and verbally and/or physically abusive to all around them. At times we get frustrated and upset, but over time we get to know each of their names and their individual needs. We are persistent, trying over and over again to help them. With each new presentation, both “sides” may begin their “games” anew. Whether the homeless to us, or we to them, become familiar or even “family”, I think all ED staff, on the whole, feel privileged to be in a position to offer not only core healthcare but also comfort and help to homeless people. This is, I believe, why we are so sad and reflective when we lose one of them. Chest x-ray of Harry, showing cavitating pneumonia

Gordian W O Fulde FRACS FRCS FACEM

To the Editor: In 1964 the Journal published an article by Barnes which solved the mystery of a distressing illness that was affecting many Queensland beachgoers — Irukandji syndrome.1 In a remarkable piece of detective work, Barnes had captured a small (25 mm bell) jellyfish and demonstrated, by allowing it to sting himself, his 9-year-old son and the on-duty lifeguard, that this jellyfish caused Irukandji syndrome. All required inpatient care. This jellyfish was named Carukia barnesi in his honour, and has been known as the “Irukandji jellyfish”. Many now believe that more than one jellyfish is responsible for Irukandji syndrome. Significantly, in the 40 years since Barnes’ discovery, no other jellyfish causing Irukandji syndrome has been identified. Here we present evidence of an identified unnamed jellyfish causing Irukandji syndrome. This information is further to a case we have previously reported, of a 24-year-old woman who developed Irukandji syndrome after being stung while snorkelling on the Great Barrier Reef.2 By the time she arrived in the emergency department she was in severe pain, had hypertension and tachycardia, and had clinical and echocardiographic signs of left ventricular failure. She was intubated 24 hours after being envenomed, and required inotropic support for 72 hours and ventilation for 8 days. Her troponin level peaked at 72 μg/L (normal, < 0.7 μg/L) and her echocardiogram demonstrated severe cardiac dysfunction, with a cardiac index of 1.7 L/min/m2. She recovered fully and was discharged home 14 days after admission. At the time, a 2 mm piece of tentacle (Box [a]), and one nematocyst (species-specific stinging cell; Box [b]), was collected from underneath the pressure immobilisation bandage on the sting site. Although we were confident that this tentacle did not come from C. barnesi (Box [d]), we were unable to identify the jellyfish. One of us (J S) has been reviewing collections of jellyfish. In the Queensland museum collection he examined a small, unnamed jellyfish (Box [c]) which was morphologically different to C. barnesi. This “new” jellyfish had gastric cirri (absence of gastric cirri is a specific characteristic of the genus Carukia) The nematocyst from our patient (Box [b]) matched the nematocysts from the Queensland museum specimen (Box [e]). We have thus identified an unnamed jellyfish whose sting resulted in life-threatening cardiac failure associated with Irukandji syndrome. This case confirms that more than one jellyfish is responsible for Irukandji syndrome. We propose that C. barnesi should no longer be known as the “Irukandji jellyfish” but the “Barnes jellyfish” in honour of its discoverer. A piece of tentacle and a nematocyst from the patient, compared with a tentacle from Carukia barnesi and with nematocysts from an unnamed jellyfish

Mark Little FACEM, MPHTM · Jamie Seymour BSc(Hons), PhD

To the Editor: The Irukandji syndrome can cause severe hypertension (over 220/110 mmHg)1 and has caused two fatalities from cerebrovascular haemorrhage.2 There is no first aid treatment for the severe pain or hypertension, so developing an effective prehospital treatment is a priority. The venom from the jellyfish that causes Irukandji syndrome (Carukia barnesi) is a sodium-channel agonist which causes massive release of noradrenaline.3 Intravenous magnesium sulfate has proven to be an effective treatment for the symptoms of Irukandji syndrome,4 but requires in-hospital monitoring. We investigated the use of sublingual glyceryl trinitrate spray (GTN), which is a vasodilator, in three sting victims, in whom it appeared to effectively control hypertension. Three patients with clinically confirmed Irukandji syndrome were given one puff of GTN sublingually for hypertension. Blood pressure (BP) was checked every minute for 5 minutes (by electronic sphygmomanometer). Further puffs of GTN were given every 5 minutes, with the aim of reducing the diastolic pressure below 100 mmHg. The treatment and clinical course of each patient is described. Patient 1 was a 43-year-old man with severe Irukandji syndrome (adrenergic symptoms, severe low-back and muscular pains) who presented 40 minutes after Carukia barnesi envenomation on an island in the Whitsundays. Despite being given 10 mg morphine intravenously, his BP was 200/112 mmHg. One puff of GTN was given, and after 5 minutes his BP was 180/120 mmHg; another puff reduced it to 170/110 mmHg, and 10 minutes after a third puff it was 160/100 mmHg. After transfer to a mainland hospital, his clinical course was stormy. His hypertension was poorly controlled by intravenous magnesium and he required intravenous nitrates and morphine. Patient 2 was a 49-year-old man with pain (for which 10 mg morphine and 50 mg promethazine were given intramuscularly), adrenergic symptoms and a BP of 182/110 mmHg 25 minutes after Carukia barnesi envenomation on a Whitsunday Island. One puff of GTN reduced his BP to 170/96 mmHg within 5 minutes; a second puff reduced it to 140/90 mmHg at a further 5 minutes. His BP remained at this level until he was transferred to hospital an hour later. Patient 3 was a 33-year-old woman with pain (treated with 10 mg morphine and 50 mg promethazine given intramuscularly), adrenergic symptoms and mild hypertension (143/98 mmHg) 35 minutes after Carukia barnesi envenomation on the same Whitsunday Island. She was given three puffs of GTN, which reduced her BP to 130/80 mmHg after 30 minutes. None of the three patients had pre-existing hypertension, or took medication. GTN reduces hypertension by vasodilation, and is now recommended for hypertension from dysreflexia in patients with spinal injury,5 in whom similar high levels of serum catecholamines occur. Further assessment of GTN use in patients with Irukandji syndrome is necessary, but we believe it should be considered as prehospital treatment under medical guidance. It is currently the recommended treatment by Ambulance Officers in the Queensland Ambulance Service.6

Peter J Fenner MD · Morris Lewin FACOG

It was one of those times when you agree to help a friend and don’t realise what you are letting yourself in for. I have known Keith for about six years through our shared love of rock climbing. We saw each other frequently at the sport climbing walls in Hong Kong and, as frequently happens in Hong Kong with the expatriate community, friends come and go, leaving the people left behind to close ranks. After a few years, Keith and I became climbing partners and a regular team in the climbing community. Keith had left the high-flying world of corporate finance to establish an adventure racing company in South-East Asia. In a way, adventure racing is an offshoot of triathlons. The competitors race in groups of two to four over a number of days in a number of different disciplines including mountain biking, running, swimming, rope skills, orienteering, caving and problem-solving exercises. At the level Keith was catering for, the racers were usually amateurs who limped back to their high-pressured jobs the day after the race had finished. As a doctor for 20 years and an anaesthetist for 14 years, Keith asked if I would volunteer to be the medical coordinator for a two-day race he was organising in an area called Yangshou in southern China. This area is famous for its magnificent limestone monoliths towering above the rice paddy fields. With such a glorious backdrop for two days (as well as an all-expenses-paid trip), how could I refuse? Frankly, my expectation of the trip was that I would be washing and dressing innumerable “gravel rashes”, with the most difficult problem being how to splint a fractured forearm or ankle in a remote location with none of the normal hospital facilities. This proved to be a very poor under-estimation of the two days. The first day started quietly enough (at least from the medical standpoint). The race started with a run, leading up to a 9.6 metre (yes, 9.6 metre) bridge jump into a river, a swim over to the riverbank and a bicycle leg. After checking that the same number of people who jumped into the river climbed out, I was given a mountain bike and told to ride 10 kilometres via a short cut to the next checkpoint before the competitors arrived. Within minutes of arriving at the checkpoint I received a call that a competitor had fallen off his bike and landed in a paddy field: back on my bike and off to find the victim. After some time, I arrived at one of the outlying villages and found a crowd of locals swarming around a foreigner leaning up against a chicken coop. He was conscious but unable to remember his accident, and was amnesic for at least five minutes around the time of his fall. He was able to remember that his first name was John, but was unable to recall his surname, or exactly where in Hong Kong he lived. His racing partner volunteered that John had failed to negotiate a tight corner and had fallen over the handlebars and landed headfirst in a ditch below the road. The total height of the fall was about 2 metres. Fortunately he had been wearing a bicycle helmet. The physical examination was unremarkable apart from a superficial graze on the top of his head and multiple small abrasions to his torso. The neurological examination was normal, and there was no spinal tenderness detectable after he was “log rolled”. The next step was to arrange his evacuation to the nearest medical facility for re-evaluation and treatment. There were no soft or hard collars available, so I rolled a towel up and wrapped it around his neck as an improvised soft collar until it could be replaced, but the question of transport was tricky. The village’s remoteness precluded four-wheeled vehicle access, and the villagers themselves either walked or rode motorbikes in and out of their farms along the walking tracks between their crops. Helicopter or fixed-wing evacuation was not a realistic option in this area of China. I contacted Keith by radio and asked for a motorbike to evacuate John out of the area. The idea of a patient with potential head and spinal injuries being evacuated sitting behind a local farmer on the back of his motor bike is not something covered by the medical textbooks but, in this situation, improvisation was mandatory. The motorbike’s progress was slow as I walked alongside in case John lost consciousness and fell off. Thirty minutes later we reached a dirt road and were met by one of the local doctors who drove John and me to Yangshou hospital. Surprisingly, Yangshou hospital has a CT scanner, and after initial assessment by one of the doctors John received a CT scan of the head and cervical region. This proved to be normal and he was discharged soon after to sit out the rest of the race in the hotel room. The cost of the hospital treatment and CT scan? US$36! The rest of the race injuries included a race official sustaining a puncture wound to the palmar surface of his left hand from a stone spike in a limestone cave. This required a second trip to Yangshou hospital, intravenous antibiotics, a tetanus injection, and a flight back to Hong Kong for an emergency operation. There were also several cases of heat exhaustion requiring intravenous fluids and, oh yes, washing and dressing of innumerable “gravel rashes”.

Keith B Greenland MBBS, FANZCA, FHKCA, FHKAM

A 46-year-old man presented to the ED after waking up to find a plastic golf tee embedded in his right thenar eminence (Figure a). His memory of how it got there was rather foggy. The tee was removed under nitrous oxide sedation (Figure b, c) and the wound was irrigated. There was no apparent neurovascular or tendon injury. The patient was given oral antibiotics and discharged, for follow-up at the Hand Clinic.

Timothy C Green MBBS FACEM

Most of the solutions lie beyond the emergency department Hospitals represent essential infrastructure. Engineers who run an essential community resource such as the water supply system at 100% of capacity might expect to lose their jobs the first time consumers had to queue to use a tap. In contrast, some hospital funding models include activity targets that reward administrators who run at 100% of capacity — a level that guarantees queuing in the emergency department for coronary care beds and other critical inpatient services. The community accepts the use of price and denial (eg, restrictions of hours or allowed uses) as a rationing mechanism for the water supply, but not for hospital beds — queuing is the only rationing method currently accepted in the hospital system. Rationing is an essential feature in modern medicine,1 and queuing has long been used to ration elective services. But queuing is fundamentally an inefficient means of rationing care for time-critical illness. Access block — the inability of patients in the emergency department (ED) to access hospital beds — is the major issue currently facing emergency medicine in Australasia2 and, indeed, the whole Western world. Given a fixed physical resource and a relatively fixed labour force, increased average total ED time,3 also called ED length of stay (EDLOS), will decrease the resources available for providing care to acutely ill patients. Access block decreases access to emergency care (eg, measured as waiting time),4 and the resultant overcrowding is associated with adverse outcomes for ED patients.5,6 It is certainly in the interests of ED staff and patients to decrease EDLOS. . . . restricting the access and quality of initial care because of inability to provide timely later care is ethically dubious . . . The article by Liew et al in this issue of the Journal 7 adds to the growing evidence for an association between EDLOS and outcomes beyond the ED.8 The authors used a multivariate approach to study the relationship between EDLOS, other confounding factors, and subsequent inpatient length of stay in three Melbourne metropolitan hospitals. They found a positive association between EDLOS and inpatient length of stay after adjusting for casemix, time of presentation, and patient age. Whether this relationship is causal is a subject for further study. The Australasian College for Emergency Medicine has committed resources to such research through the Emergency Medicine Research Foundation. From an administrative perspective, the underlying mechanism is less important than the result. Increased inpatient length of stay after correction for casemix is financially undesirable: it is in the interest of hospital management to reduce both EDLOS and inpatient length of stay. Emergency departments are specialist multidisciplinary units with expertise in managing acutely unwell patients for the first few hours in hospital. Neither the facilities (generally poor privacy, small trolleys, 24-hour lighting) nor the staff are appropriate for providing longer term inpatient care. Very few patients who require an inpatient bed benefit from staying in the ED longer than 4 hours, and no ED benefits by caring for patients beyond this time. If the 30% or so of patients who are admitted spend twice as long in the ED, this represents a 30% increase in workload for ED staff with no change in conventional measures of activity (presentations, admission rate). Steadily worsening delays in accessing inpatient beds have been documented in many EDs over the past decade,9 suggesting there might be an underlying incentive such as increased efficiency in a different part of the health system. This research demonstrates an association with increased opportunity costs rather than any benefits. There is a clear need to reduce EDLOS for patients, but most of the solutions lie beyond the ED.10 Changes within the ED can mitigate the effects of increased workload, but, because of access block, they cannot shorten EDLOS. Much can be done to improve our hospital systems, including use of protocols for common conditions, transparent bed-management processes, and a focus on efficient use of the available beds, particularly through admission and discharge planning. Clinicians must be willing to trial different methods of management, such as treatment in the home and accelerated discharge, and to evaluate the outcomes rigorously.10 The study by Liew et al identifies the elderly as a group with the greatest potential for effective intervention. There have been significant achievements and more can be expected, but process change will not completely address the underlying mismatch between demand for inpatient beds and resources available. The primary problem is the lack of acutely available beds.11,12 The scarcer those empty beds become, the more difficult they are to access. Queuing for care at the entrance to ED is managed by triage, which stratifies patients by urgency — the most time-critical cases have the shortest queues. Queuing for a bed at the exit of ED is managed by bed allocation, which tends to stratify patients by their nursing load — the least intensive cases generally have the shortest queues. Elementary queuing theory predicts the accumulation of patients, but the daily variation in emergency medical activity has for too long allowed both emergency staff and others to assume the ED has “rubber walls” and that the marginal cost of the ED absorbing additional care to inpatients is low. The study by Liew et al7 and other studies on the effects of overcrowding5,6,13 now provide clear evidence that this is not the case. Emergency departments are expert at triage to achieve “the greatest good for the greatest number”, but, when prioritising, even emergency physicians are reluctant to consider denying care to patients with whom they have begun a therapeutic relationship. EDs are faced with the ridiculous situation of providing many hours of care to patients whose conditions were urgent on arrival but stable after treatment, while potentially unstable patients of similar initial urgency languish in the waiting room or in an ambulance for want of an ED trolley and nurse. It is time that hospitals addressed this inequity: restricting the access and quality of initial care because of inability to provide timely later care is ethically dubious14 and is likely to lead to adverse outcomes and medicolegal exposure. These weighty issues cannot be addressed by EDs alone. Demand for emergency services has increased9 while bed numbers have decreased,15 and demographic projections indicate that these trends are unlikely to reverse. Unless practices change, our EDs will cease to function in their designated role, and will instead inappropriately spend most of their resources providing care to patients who should be in inpatient beds. Hospitals, communities, and government must debate and decide the allocation of resources to EDs and wards and agree on a sensible approach to providing appropriate care in both environments. The debate is no longer about the level of resources our EDs deserve, but rather about how to ensure that ED resources are directed to those who need them — the patients in the waiting room.

Drew B Richardson MB BS(Hons), FACEM

Objective: To examine the association between emergency department length of stay (EDLOS) and inpatient length of stay (IPLOS).Design: Retrospective review of presentations and admissions data.Setting: Three metropolitan hospitals in Melbourne, 1 July 2000 to 30 June 2001.Main outcome measures: Mean IPLOS for four categories of EDLOS (≤ 4 hours, 4–8 hours, 8–12 hours, >12 hours); excess IPLOS, defined as IPLOS exceeding state average length of stay; odds ratios for excess IPLOS adjusted for age, sex and time of presentation.Results: 17 954 admissions were included. Mean IPLOS for the four categories of EDLOS were ≤ 4 hours, 3.73 days; 4–8 hours, 5.65 days; 8–12 hours, 6.60 days; > 12 hours, 7.20 days (P < 0.001). The corresponding excess IPLOS were 0.39, 1.30, 1.96 and 2.35 days (P < 0.001). Compared with EDLOS 4–8 hours, odds ratios (95% CIs) for excess IPLOS associated with the other three categories of EDLOS were ≤ 4 hour, 0.68 (0.63–0.74); 8–12 hours, 1.20 (1.10–1.30); and > 12 hours, 1.49 (1.36–1.63), after adjusting for elderly status, sex and time of ED presentation.Conclusion: EDLOS correlates strongly with IPLOS, and predicts whether IPLOS exceeds the state benchmark for the relevant diagnosis-related group, independently of elderly status, sex and time of presentation to ED. Strategies to reduce EDLOS (including countering access block) may significantly reduce healthcare expenditure and patient morbidity.

Don Liew MB BS, FACEM · Danny Liew MB BS(Hons), FRACP · Marcus P Kennedy MB BS, FACEM

The concept of “first-responder” defibrillation is not being embraced The article in this issue of the Journal by Finn and Jacobs (page 470)1 challenges our professions to find better ways of dealing with sudden unexpected cardiac arrest in the nation’s hospitals — that is, in those places which should be best able to deal with it. Nurses, with a nursing perspective, wrote the article. It underscores the important role played by nurses, and the problem that needs to be addressed by nurses through their influence within our hospitals. Australia played a major role in initiating coronary care wards for managing ventricular fibrillation (VF) in the early stage of myocardial infarction, through the work of Desmond Julian at Sydney Hospital2 and Graeme Sloman at Royal Melbourne Hospital3 during 1961 and 1962. While now taken for granted, one is apt to forget how controversial this development initially was, and how poor the initial results were until nurses were permitted to use defibrillators and so shorten the time from cardiac arrest to termination of VF. At the time, physicians claimed the high ground — defibrillators were too dangerous to be entrusted to nurses — ignoring the fact that the first article on successful use of external defibrillators was written in 1960 by two engineers and one surgeon.4 Fortunately, reason and logic triumphed, and defibrillation became the most important priority for coronary care unit and intensive care unit nurses, with a doctor being summoned concurrently, and usually arriving in time to document return of consciousness and plan ongoing management. Such pioneering work was followed by the development of automatic internal and external defibrillators (AIDs and AEDs, respectively). These are able to sense and interpret VF, and will operate and deliver a shock only if VF is present. They are small and ubiquitous. The US Vice-President, Dick Cheney, has an implanted AID. Indeed, the man who is “a heartbeat behind” the world’s most powerful man is himself “a heartbeat behind” (obviously a number of heartbeats behind) the scrutiny of an automatic implanted defibrillator. Implantation is one mode of use for defibrillators in people at high personal risk of VF. Another mode is public access defibrillation, where AEDs are placed in public places, like fire extinguishers, for use by minimally trained or untrained people, who apply chest pads to an unconscious person and respond to voice prompts delivered by the device. Providing such devices in Chicago’s airport complexes (Box) has resulted in long-term, neurologically intact survival of 56% of sudden cardiac arrest victims, compared with no cases of neurologically intact survival before the devices were made available.5 One of us (C S D) is responsible for a national program,6 in which nearly 700 defibrillators have been installed in airports, train stations, and other busy public places across England. Early results suggest that 29 people have survived to hospital discharge after sudden cardiac arrest. The downside has been minimal, with no injury from use, and virtually no theft, misuse or vandalism. Other highly favourable experiences involving police and the community have recently been reported.7,8 What relevance does the community experience have for Australian hospitals? Finn and Jacobs have identified a number of anomalies. Certainly, AEDs are now available in many Australian hospitals, so that training for nurses in their use is easier, less formidable, and less costly. But most Australian hospitals (57%) still do not have these devices. In hospitals with any kind of defibrillator, 16% in Australia do not permit nurses to defibrillate; in those with AEDs, this figure is 9%. This practice persists despite the knowledge that survival decreases by 10% for each minute that passes after onset of VF until defibrillation is achieved — automatically by an implanted defibrillator, or with manual intervention after placement of pads by doctor, nurse — by anyone. It matters not who places the pads and pushes the button, but hospital procedures are often based on the view that it does. The outcome, demonstrated by hospital, national and published data, is that cardiac arrest is more successfully treated in Chicago or Heathrow airport, on an American Airlines or Qantas jet, or in a Boston post office, than in the vestibules, corridors or general wards of Australia’s premier hospitals. An example of the existing problem is shown in the Box, which contrasts the well signed, alarmed, and easily accessible defibrillator at O’Hare Airport with the unsigned, unalarmed, padlocked defibrillator in the corridor of a major Australian hospital. Providing a defibrillator in such a way is a contemptuous gesture to modern knowledge, and to pronouncements of the Australian Resuscitation Council, as described by Finn and Jacobs. This “AED in a cage” symbolises the problems exposed by Finn and Jacobs,1 and illustrates the 1960s view — that defibrillation is the preserve of the enlightened few with access to the key. We are not overly concerned with the issue raised by Finn and Jacobs in relation to CPR training for medical staff. Their survey was sent to directors of nursing and the replies reflect the nursing perspective, which may not include full knowledge of medical staff activities. Medical practitioners usually prefer to train themselves in resuscitation, and there are surely few who cannot initiate CPR or use a defibrillator, so the number of hospitals identified as offering CPR training to doctors may not be important. We are delighted to see how many hospitals train lay staff in resuscitation. Hopefully, the future will see more communication between doctors, nurses and lay staff at hospitals where issues of “turf”, keys, and locked cages can be resolved, and where the chain of survival can be initiated expeditiously wherever and whenever the need arises. Forty years ago, the Australian hospital system was slow to pick up on the inspirational but logical initiative of Julian, Gaston Bauer (who recruited Julian to Sydney Hospital and encouraged subsequent developments) and Sloman. It remains slow in throwing off the shackles of officialdom. Finn and Jacobs are to be complimented on their fine work. Two approaches to providing automatic external defibrillators (AEDs) One of the many AEDs deployed along a concourse of Chicago’s O’Hare Airport. The device is clearly signposted (not seen in picture), alarmed, and connected by automatic phone to the emergency medical centre. AED in a corridor of a major Australian hospital. There is no signposting, the case is locked and no advice is given on the location of the key.

Michael F O’Rourke AM, MD, FRACP · C Siân Davies MBE, RN

Michael J O’Leary Intensive Care Physician, St George Hospital, Gray Street, Kogarah, NSW 2217. m.olearyATunsw.edu.au To the Editor: Hore and colleagues argue for “integrated critical care” as a solution to the problem of providing intensive-care cover for patients in rural and non-tertiary metropolitan hospitals.1 They claim that such an approach is required uniquely in these hospitals, whereas in tertiary centres “subspecialists would be involved in each phase of the management process”. That this occurs is undisputed; however, it is far from the optimal model of care.2 Over the past 3 decades, the management of critically ill patients has evolved to require its own specialty. Other than in the traditional critical-care disciplines of anaesthesia and emergency medicine, training in critical care is not a significant component of specialty training programs. Within tertiary hospitals, therefore, the requirement that critically ill patients be cared for by specialists trained in critical-care medicine (and not a “committee” of subspecialty experts) is no less important than in the rural setting. There is consequently little difference between the skills and experience required of tertiary and rural critical-care specialists, and the continuum of critical care is the same in both settings. The recent creation of the Joint Faculty of Intensive Care Medicine by the Royal Australasian College of Physicians (RACP) and the Australian and New Zealand College of Anaesthetists (ANZCA) has enabled many of the past artificial barriers to effective critical-care training and accreditation in Australasia to be broken down. It is now possible to enter intensive-care training from varied training programs, including those of the Australasian College for Emergency Medicine, the RACP and the ANZCA. Completion of training is recognised by successfully passing a broad-based critical-care examination. The argument that training could and should include rural practice is well made. However, any comprehensive critical-care training will inevitably require some high-volume experience only available within a tertiary institution. That there are differences in emphasis in the workload of our rural colleagues should be recognised. However, our job is essentially the same. There is no need for a separate specialty, but there is a need to ensure provision of high quality critical-care services to all patients into the future.

Michael J O’Leary